Menningococcal Septacaemia

[air.stump]

I have worked two services in Texas where we administered IV antibiotics, however they were only for trauma. As Zilla points out, it would be extremely uncommon for EMS to pick up a patient in the field that presented so clearly that an empirical diagnosis of meningococcaemia could be comfortably made. I don't know how such a thing could really work out in EMS. Every kid with febrile BOM would end up full of Rocephin, which would be a very bad thing. The signs are obviously clearer in adults, but still certainly not an easy empirical call, and the gravity of the situation certainly wouldn't necessitate immediate treatment versus a simple fifteen minute ride to the hospital.[/quote

I think it would work out fine in EMS. I think this because most of the reasons that kids would get LP's in the peds ER I worked in was for a fever and or other symptoms that the doc could see. Up to a certain age, a septic work up and a treatment that was geared to stop meningitis from progressing is done routinely. As the age of the patient increased, more emphases was placed on the clinical presentation of the patient. These symptoms are recognizable for most EMS providers of any level.

[chbare]

I am not sure I understand your argument. Yes, we work up many people for meningitis. However, many will not actually have bacterial meningitis. Many cases of true bacterial meningitis will present with rather generalized signs and symptoms. In addition, many cases of meningitis are caused by a virus. I cannot see how EMS providers throwing antibiotics at people who may have meningitis will be very helpful.

I understand many people advocate the "shotgun" approach to antimicrobial therapy, and will argue that there is no harm in hitting people with an antibiotic if meningitis is suspected. However, I disagree. Over zealous use of antibiotics in the long run seems to be causing many problems. Again, I have seen many patients with viral syndrome present with meningitis like signs and symptoms. I am not sure throwing a third generation cephalosporin at all of these patients is a good idea IMHO.

Funny, we are arguing about a reactive plan to treat something that we cannot definitively identify as EMS providers; however, very few people have discussed the proactive measures that can help prevent meningitis and the spread of meningitis. Patient and family education and vaccination, and HIV education and treatment.

Take care,

chbare.

[air.stump]

chbare,

I agree with you in that AB therapy shouldn't be thrown around haphazardly to every kid/patient with photophobia, nuccal rigidity, fever, rash,........ I am saying that with the proper protocols and medical direction, it could be an option for EMS'ers, like our colleagues in Sussex, who have longer transport times.

It is true that a lot of patients that present with symptoms of bacterial meningitis end up being viral once the gram stain and cultures are completed. There are also a decent percentage of patients, mostly kids, that have negative cultures and gram stains and still receive AB therapy. As bad as it may be, many kids less than one year of age, that show up in a ER with a temp greater than 102 and without a condition that could cause the fever, receive AB therapy.

My position is that AB therapy in the prehospital setting is a tool that could find some use on a limited basis. Which situations, which drugs, and protocols are something that the medical director should determine.

We don't administer AB therapy in the prehospital setting in Mississippi.

[logos]

chbare,

I agree with you in that AB therapy shouldn't be thrown around haphazardly to every kid/patient with photophobia, nuccal rigidity, fever, rash,........ I am saying that with the proper protocols and medical direction, it could be an option for EMS'ers, like our colleagues in Sussex, who have longer transport times.

It is true that a lot of patients that present with symptoms of bacterial meningitis end up being viral once the gram stain and cultures are completed. There are also a decent percentage of patients, mostly kids, that have negative cultures and gram stains and still receive AB therapy.

You actually don't even really need to wait to get the cultures/gram stain back. Just the CSF glucose and total protein should be sufficient to justify starting antibiotics in the right clinical scenario. You'd then expect the cultures to confirm in the next day or two.

Actually, that thought brings up another potential issue with prehospital antibiotics. Generally, it is considered best to collect specimens for culture prior to initiating treatment. If antibiotics are administered, the likelyhood of cultures growing will fall. This leads to diagnostic uncertainty and may commit the treating physician to completing the antibiotic course even in the face of poor clinical indications for continued therapy (for medicolegal reasons).

Another thing to keep in mind is that the above mentioned penicillin family antibiotics wont cover all causes of bacterial meningitis (most...but not all). The big uncovered group would be certain strains of pneumococcus.

[Dustdevil]

I think this because most of the reasons that kids would get LP's in the peds ER I worked in was for a fever and or other symptoms that the doc could see. Up to a certain age, a septic work up and a treatment that was geared to stop meningitis from progressing is done routinely. As the age of the patient increased, more emphases was placed on the clinical presentation of the patient. These symptoms are recognizable for most EMS providers of any level.

Air, I don't know anything about your educational or experiential background. I would assume that it is probably above average for an EMS provider. But I'm afraid that some of us are going to have to immediately conclude that you could use a serious review of microbiological principles, as well as paediatric and clinical medicine. As already pointed out by others, none of what I just quoted is valid.

And I find it difficult to believe that anybody who reads the horror stories on this forum everyday would actually think that "most EMS providers of any level" have the education and clinical sophistication necessary to easily diagnose bacterial meningococcaemia. Half the providers in the country still cannot accurately diagnose an AMI.

Fifteen minutes. Thirty minutes. Sixty minutes. Ninety minutes. Doesn't matter how long your transport time is. The frequency of occurrence for meningococcaemia, and the immediate benefit of antibiotic therapy simply do not add up to a positive risk vs. benefit ratio utilising "most EMS providers of any level" in this country who never have -- and never will -- take a microbiology course because, "I don't need all that book learnin'!".

[air.stump]

Logos,

Excellent point about waiting to collect the specimens before initiating treatment. If cultures show growth, the AB therapy is usually adjusted to cover the bug that grows.

Dust,

You make valid points. I understand that most EMSer's won't involve themselves in a microbiology course. They have no interest and I can understand that, some of that stuff is just boring to some. So, let me restate my position and pose a scenario to you.

AB therapy has a place in EMS and prehospital medicine. That place is to be determined by medical directors that will apply AB therapy to very narrow protocols.

Now the scenario.

You respond to a call of 30 y/o male with a cough for two months.

On the scene, you note that the house is in a lower socio-economic section of town. Also noted is that the windows are covered up and the inside of the house is dark and warm. The patient is sitting on the couch and you notice a couple of paper towels stained sulfur yellow with bloody sputum beside him. He tells you he has a cough, a fever, he has lost about twenty pounds over the last month no matter how much he eats. He is tired all the time and has night sweats. My spidey senses are telling me to put on a mask and mask the patient because I suspect TB.

Now with all that said, why couldn't a fellow EMSer come to a conclusion about treatment with symptoms of meningitis?

[VentMedic]

The patient is sitting on the couch and you notice a couple of paper towels stained sulfur yellow with bloody sputum beside him. He tells you he has a cough, a fever, he has lost about twenty pounds over the last month no matter how much he eats. He is tired all the time and has night sweats. My spidey senses are telling me to put on a mask and mask the patient because I suspect TB.

Now with all that said, why couldn't a fellow EMSer come to a conclusion about treatment with symptoms of meningitis?

Do you know how many times I have tossed a box of N-95s in the direction of EMS crews as they enter the ED because they didn't recognize the symptoms. We've also had threads on this forum and others discussing the very basics of TB, skin testing and precautions. Do you know how many times I have had to take Cipro from incidental Meningococcus exposure in the ED by patients brought in by EMS? Anytime I hear the words "flu like symptoms" come out of a Paramedic's mouth I mask at 30 paces now.

[Dustdevil]

AB therapy has a place in EMS and prehospital medicine. That place is to be determined by medical directors that will apply AB therapy to very narrow protocols.

I absolutely agree with that, especially in the rural and wilderness/frontier setting. It's just that none of the scenarios you have presented so far -- including the mushroom gardener -- would qualify as a proper place for field antibiotic therapy.

When you bring that patient into the ER, there is no physician on earth who is going to initiate immediate abx therapy without first doing a CXR, labs, and a more thorough physical exam than we are capable of. If he's not in a big hurry, then why should we be? Yeah, if the patient is positive active TB, he is going to need antibiotics, but it is not an emergent need. And that need should be tailored to the patient. Treat the patient, not the disease.

And we don't give drugs just because we can. We give them because they are needed. I'm still waiting for you to present a patient that actually needs them, because I am not risking full-blown anaphylaxis thirty minutes to an hour away from the hospital to give an IV antibiotic just because "I can".

[jmac]

wow looks like this thread is going the same way as most here, full blown anaphylaxis????

according to the stats on deaths from anaphylaxis due to allergy to penicillin in the UK over a period of 10 yrs is 27, those are good odds.

this is an international forum, why is it if something is done outside of the US it is either done badly or is inappropriate to some here, and why do some here, for all their preaching on the need for education, cut most EMS providers off at the knees in the US and say that they " don't have the education or are too lazy to get it "

In other countries (non-US), pre-hosp providers are giving anti-bi's, thrombolytics ect, this is advancement, this is education for the pre-hosp environment, no matter how much time in the lab doing courses on micro or lab work, maybe good education but ain't really gonna help you in the field.

why does every thread on here go down the line of a few philosophers telling their opinion on what should be, maybe they should take a leaf from their own books and look outside the box, not stay in the tunnel

[air.stump]

Jmac, you have a point. Us stateside EMSer's have a hard time seeing the other side of an argument let alone the other side of the world. You are also absolutely right in that in other parts of the world, there are some great things happening in prehospital care. My next question would be in what protocols do you give AB beside trauma?

I think that certain trauma situations would be the first protocols to receive the go ahead for AB therapy here.

As for the education comment, I also agree. There seems to be a consensus in our profession that once you graduate and obtain your license, your education stops. IMHO that is where your education begins. Not with the bare minimal requirements to maintain your license but with courses that add to instead of refresh your your education.

Dustdevil. We agree on the basic points but disagree on the details. I think you are absolutely right on the "We don't give drugs just because we can." statement. But.......... Doczilla said, "The problem with meningitis is that if it clinically evident without doing the LP, likely the patient is in deep s#it." This goes back to my assessment position. Prehospital providers can look at a set of symptoms and make an accurate deduction. This is where the protocol, on-line med control and AB therapy could merge together. We can agree to disagree on this one. I liked the mushroom farmer comment too. Except he wasn't a farmer but a radiologist working from home online.